Abstract:

A surgical access device is adapted for performing laparoscopic surgical
procedures with at least one instrument passing through the surgical
access device and through an incision in the abdominal wall of a patient
with the abdominal cavity pressurized with an insufflation gas. The
surgical access device is adapted to provide instrument access to the
abdominal cavity for surgical procedures while generally maintaining
insufflation pressure in the abdominal cavity. The surgical access device
comprises an access seal. The access seal comprises a material formed of
a mixture comprising a triblock copolymer and an oil. The access seal is
adapted to be disposed relative to the abdominal wall in an operative
position. The material of the access seal is adapted to form a seal to
generally maintain insufflation pressure within the abdominal cavity. At
least one opening is formed through the material of the access seal
between a proximal portion and a distal portion of the access seal. The
at least one opening when operatively disposed is in communication with
the incision and forms a working channel between a location external to
the abdominal wall and a location internal to the abdominal wall. The
material of the access seal is adapted to conform to a surface of an
instrument inserted through the working channel.

Claims:

1. A surgical access device adapted for performing laparoscopic surgical
procedures with at least one instrument passing through the surgical
access device and through an incision in the abdominal wall of a patient
with the abdominal cavity pressurized with an insufflation gas, the
surgical access device adapted to provide instrument access to the
abdominal cavity for surgical procedures while generally maintaining
insufflation pressure in the abdominal cavity, the surgical access device
comprising:an access seal, the access seal comprising a material formed
of a mixture comprising a triblock copolymer and an oil, wherein the
access seal is adapted to be disposed relative to the abdominal wall in
an operative position, and wherein the material of the access seal is
adapted to form a seal to generally maintain insufflation pressure within
the abdominal cavity; andat least one opening formed through the material
of the access seal between a proximal portion and a distal portion of the
access seal, wherein the at least one opening when operatively disposed
is in communication with the incision and forms a working channel between
a location external to the abdominal wall and a location internal to the
abdominal wall, wherein the material of the access seal is adapted to
conform to a surface of an instrument inserted through the working
channel.

2. The surgical access device of claim 1, further comprising a trocar
configured for placement through the opening.

3. The surgical access device of claim 1, wherein the at least one opening
accommodates a range of instrument diameters.

4. The surgical access device of claim 1, wherein the material of the
access seal is adapted for direct contact with the abdominal wall during
use.

5. The surgical access device of claim 1, wherein the material of the
access seal is adapted for direct contact with the instrument during use.

11. A surgical access device adapted for performing laparoscopic surgical
procedures with at least one instrument passing through the surgical
access device and through an incision in the abdominal wall of a patient
with the abdominal cavity pressurized with an insufflation gas, the
surgical access device adapted to provide instrument access to the
abdominal cavity for surgical procedures while generally maintaining
insufflation pressure in the abdominal cavity, the surgical access device
comprising:an access seal, the access seal comprising an elastomeric
material formed of a mixture comprising a triblock copolymer, wherein the
access seal is adapted to be disposed relative to the abdominal wall in
an operative position; andat least one access channel formed through the
elastomeric material between a proximal portion and a distal portion of
the access seal, wherein the at least one access channel when operatively
disposed forms at least a portion of a working channel between a location
external to the abdominal wall and a location internal to the abdominal
wall;wherein the elastomeric material of the access seal is adapted to
conform to a surface of an instrument inserted through the working
channel to provide instrument access to the abdominal cavity while
generally maintaining insufflation pressure in the abdominal cavity.

12. The surgical access device of claim 11, wherein the access seal is
adapted to maintain a sealing relationship with a plurality of
instruments positioned through the access seal while accommodating
relative movement between the plurality of instruments.

13. The surgical access device of claim 11, wherein the at least one
access channel is configured to self seal in the absence of any
instrument extending through the at least one access channel.

14. The surgical access device of claim 11, wherein the elastomeric
material is a thermoplastic elastomer.

15. The surgical access device of claim 11, wherein the access seal in the
operative position is adapted to form a seal with the abdominal wall.

16. The surgical access device of claim 11, wherein the triblock copolymer
has a Styrene-Ethylene/Butylene-Styrene structure.

18. The surgical access device of claim 11, wherein the elastomeric
material of the access seal spans a thickness of the abdominal wall.

19. A method of using a surgical access device adapted for performing
laparoscopic surgical procedures with at least one instrument passing
through the surgical access device and through an incision in the
abdominal wall of a patient with the abdominal cavity pressurized with an
insufflation gas, the surgical access device adapted to provide
instrument access to the abdominal cavity for surgical procedures while
generally maintaining insufflation pressure in the abdominal cavity, the
method comprising:providing an access seal, the access seal comprising an
elastomeric material formed of a mixture comprising a triblock copolymer,
and at least one access channel formed through the elastomeric material
between a proximal portion and a distal portion of the access
seal;disposing the access seal relative to the abdominal wall in an
operative position, wherein the at least one access channel when
operatively disposed forms at least a portion of a working channel
between a location external to the abdominal wall and a location internal
to the abdominal wall; andinserting at least one instrument through the
working channel, wherein the elastomeric material of the access seal
conforms to a surface of the instrument inserted through the working
channel to provide instrument access to the abdominal cavity while
generally maintaining insufflation pressure in the abdominal cavity.

20. The method of claim 19, wherein the mixture comprises an oil.

Description:

CROSS-REFERENCE TO RELATED APPLICATION

[0001]This application is a continuation of U.S. application Ser. No.
12/360,710, filed Jan. 27, 2009, which is a continuation of U.S.
application Ser. No. 11/244,647, filed Oct. 5, 2005, now U.S. Pat. No.
7,481,765, which is a continuation of U.S. application Ser. No.
10/381,220, filed Mar. 20, 2003, now U.S. Pat. No. 7,473,221, which is
the National Phase application under 35 U.S.C. §371 of International
Application No. PCT/US2001/029682, filed Sep. 21, 2001, which published
in English as International Publication No. WO 2002/034108 A1 on May 2,
2002, which claims the benefit of U.S. application Ser. No. 60/241,958,
filed Oct. 19, 2000, all of the disclosures of which are incorporated by
reference.

BACKGROUND OF THE INVENTION

[0002]1. Field of the Invention

[0003]This invention relates generally to devices and other apparatus
facilitating sealed access with surgical instruments, such as a surgeon's
hand, across a body wall and into a body cavity.

[0004]2. Background of the Invention

[0005]In several areas of surgery there exists a need to have mechanisms
or devices that can seal a body cavity or space, and yet permit the
introduction of surgical instruments such as guidewires, endoscopes, and
even the hand of a surgeon. Typical of these areas of surgery is
laparoscopic surgery which relies on surgical instruments inserted
through the abdominal wall to reach an operative site within the
abdominal cavity. In order to increase space around the operative site
within the cavity, insufflation gases are typically introduced to inflate
the cavity and elevate the abdominal wall. This pressurizing of the
abdominal cavity is referred to as pneumoperitoneum. In this context, the
need to seal the body cavity or space arises from the need to maintain
the pneumoperitoneum even when instruments are present.

[0006]Trocars have been commonly used to provide instrument access in
laparoscopic surgeries. These trocars have included elaborate seal
structures having zero seals which prevent escape of the gases in the
absence of instruments, and instrument seals which prevent escape of the
gases in the presence of instruments. Unfortunately, the instrument seals
have been able to accommodate only a narrow range of instrument
diameters. Where wider ranges were desired multiple seal pairs had to be
provided.

[0007]Some instruments, such as the hand of the surgeon, have been too
large for trocar access. Under these circumstances, hand-assisted
laparoscopic seals have been provided. Such devices have been large,
cumbersome, and largely ineffective in providing the required sealing
mechanism. Other access devices, such as Touhy-Borst seals, have been
used but only for very small diameter access such as that required by a
guidewire.

[0008]Each of the prior devices suffers from drawbacks which make the
device difficult or cumbersome to use. For example, a Touhy-Borst seal
requires two hands to use and does not form a seal when a guidewire or
other device is about to be introduced. Present trocar seals and
hand-assisted seals require two valves, one forming an instrument seal in
the presence of the instrument, and the other forming a zero seal in the
absence of the instrument. For example, in hand-assisted devices,
elaborate mechanisms have been required to seal around the surgeon's arm.
When the arm is removed, a separate zero seal has been required to
prevent the escape of blood or insufflation gases.

SUMMARY OF THE INVENTION

[0009]These deficiencies of the prior art are overcome with the present
invention which includes both a seal apparatus and a method for using
this apparatus to perform elaborate surgeries. In one embodiment, the
device includes a valve structure formed of a gel including, for example,
a thermoplastic base such as KRATON (a trademark of Shell Corporation)
and an oil. The resulting elastomer has an excellent tear strength,
elongation greater than 1,000 percent, a very low durometer or hardness,
and biocompatibility. A process for manufacturing this device is greatly
simplified using molding techniques.

[0010]Importantly, the access device can function as both a zero seal and
an instrument seal. Furthermore, it can accommodate a full range of
instrument diameters, such as a range from two French in the case of a
guidewire, to three or four inches in the case of a surgeon's hand. In
addition, several instruments can be accommodated at the same time with a
single access device.

[0011]Both tear resistance and sealing capability can be enhanced by
encapsulating the gel in a sheath or otherwise providing circumferential
reinforcement for the valve structure. Additives can be provided either
on or in the gel to enhance properties such as lubricity, appearance,
wound treatment and/or protection, anti-cancer protection and
anti-microbial protection. Additional chemicals, compounds,
pharmaceuticals or even mechanical devices can be mixed with or embedded
in the gel material to vary chemical, pharmaceutical or physical
properties of the access device.

[0012]These and other features and advantageous of the invention will be
clarified with a description of preferred embodiments and reference to
the associated drawings.

DESCRIPTION OF THE DRAWINGS

[0013]FIG. 1 is a perspective view showing a patient prone on an operating
table with his abdomen insufflated, and with instrument access provided
by trocars and the access device of the present invention;

[0014]FIG. 2 is an enlarged side elevation view of the access device of
FIG. 1 operatively disposed exteriorly as the abdominal wall;

[0015]FIG. 3 is a side elevation view similar to FIG. 2 showing the access
device operatively disposed interiorly of the abdominal wall;

[0016]FIG. 4 is a side elevation view similar to FIG. 2 showing the access
device operatively disposed within an incision in the abdominal wall;

[0017]FIG. 5 is a plan view taken along lines 5-5 of FIG. 2;

[0018]FIG. 6 is a side elevation view similar to FIG. 2 and illustrating a
further embodiment of the access device having an external flange and an
internal flange;

[0019]FIG. 7 is a side elevation view similar to FIG. 6 and illustrating
the hand of a surgeon being inserted through the access device;

[0020]FIG. 8 is an axially cross section view of the access device
illustrated in FIG. 6;

[0021]FIG. 9 is a cross section view similar to FIG. 8 and illustrating an
embodiment with circumferential reinforcement members;

[0022]FIG. 10 is an axial cross section view similar to FIG. 9 and
illustrating a double-ring retractor with an access device of the present
invention;

[0023]FIG. 11 is a radial cross section view similar to FIG. 8 and
illustrating an embodiment having a lead-in cavity or pocket;

[0024]FIG. 12 is a top plan view of the embodiment illustrated in FIG. 11;

[0025]FIG. 13 is an axial cross section view taken along lines 13-13 of
FIG. 12;

[0026]FIG. 14 is an axial cross section view taken along lines 14-14 of
FIG. 12;

[0027]FIG. 15 is an axial cross section view similar to FIG. 13 and
illustrating an embodiment with a duct-bill valve;

[0028]FIG. 16 is an axial cross-section view taken along lines 16-16 of
FIG. 15;

[0029]FIG. 17 is a radial cross section view similar to FIG. 13 comprising
a softer hand seal and a firmer base seal;

[0030]FIG. 18 is an axial cross section view taken along lines 18-18 of
FIG. 17;

[0031]FIG. 19 is an axial cross section view of an embodiment having a
lead-in cavity or pocket with a conical or funnel configuration;

[0032]FIG. 20 is a top plan view of the embodiment illustrated in FIG. 19;

[0033]FIG. 21 is an axial cross section view similar to FIG. 13 and
showing another embodiment with a trapezoidal slit;

[0034]FIG. 22 is an axial cross section view taken along lines 22-22 of
FIG. 21;

[0035]FIG. 23 is an axial cross section view similar to FIG. 22 taken
along lines 23-23 of FIG. 21 and illustrating a slit having other than a
perpendicular relationship to the plane of the pad;

[0036]FIG. 24 is a perspective view of a further embodiment of the access
device having an opening formed by multiple slits angularly disposed and
axially spaced relative to each other;

[0037]FIG. 25 is a side elevation view of an access device with a slit
having a spiral configuration;

[0038]FIG. 26 is a top plan view of an access device having a spiral slit
and axial channel;

[0039]FIG. 27 is a side elevation view of an embodiment having a spiral
slit and a septum seal;

[0040]FIG. 28 is an axial cross section view of a further embodiment
including a superelastic conical seal and a flexible base with annular
spoke-like cams;

[0041]FIG. 29 is an axial cross section view taken along lines 29-29 of
FIG. 22;

[0042]FIG. 30 is an axial cross section view taken along lines 30-30 of
FIG. 22;

[0043]FIG. 31 is an axial cross section view similar to FIG. 28 and
illustrating an embodiment including flappers;

[0044]FIG. 32 is a perspective exploded view of a further embodiment
including a gel cap, a base, and a retraction sheath;

[0045]FIG. 33 is a top plan view of the gel cap of FIG. 32;

[0046]FIG. 34 is an axial cross section view taken along lines 34-34 of
FIG. 33;

[0047]FIG. 35 is a top plan view of the base illustrated in FIG. 32;

[0048]FIG. 36 is an axial cross section view taken along lines 36-36 of
FIG. 35;

[0049]FIG. 37 is a side elevation view of the retraction sheath
illustrated in FIG. 32;

[0050]FIG. 38 is a side elevation view of a further embodiment of the
retraction sheath;

[0051]FIGS. 39-42 illustrate progressive steps in a preferred method of
use associated with the embodiment of FIG. 32;

[0052]FIG. 39 is a top plan view showing use of a template;

[0053]FIG. 40 is a top plan view of showing placement of the retraction
sheath;

[0054]FIG. 41 is a top plan view showing placement of the base ring and
securement of the traction sheath; and

[0055]FIG. 42 is an axial cross section view partially in section showing
placement of the gel cap relative to the base.

DESCRIPTION OF PREFERRED EMBODIMENTS AND BEST MODE OF THE INVENTION

[0056]A patient is illustrated in FIG. 1 and designated generally by the
reference numeral 10. The patient 10 is shown in a prone position on an
operating table 12, where abdominal surgery is being performed by a
surgeon 14 having an arm 16 and a hand 17. In the illustrated example,
the operative procedure is performed within an abdominal cavity 18 with
instrument access provided through an abdominal wall 21. In this type of
operation, commonly referred to as laparoscopic surgery, trocars 23 and
25 are commonly used to provide minimally invasive access through the
abdominal wall 21 for instruments such as a grasper 27 and an endoscope
30

[0057]Although the specific focus of this disclosure will be on a
preferred laparoscopic procedure, it will be noted that laparoscopic
surgery is merely representative of a type of operation wherein a
procedure can be performed in a body cavity with minimal access through a
body wall.

[0058]Notwithstanding the foregoing generality, it is important to note
that with respect to laparoscopic surgery, it is often desirable that the
surgeon 14 be able to insert his/her hand 17 through the abdominal wall
21 and into the abdominal cavity 18. This insertion of the hand 17
provides the surgeon 14 with direct access to various elements of the
anatomy

[0059]In order to accommodate the hand 17 and arm 16 of the surgeon 14, a
small incision 32 is typically created in the abdominal wall 21. An
access device 34 of the present invention can be provided to further
facilitate this access by the hand of the surgeon 14.

[0060]Particularly in the case of laparoscopic surgery, it is advantageous
to insufflate the abdominal cavity 18 with a gas, such as carbon dioxide,
in order to elevate the abdominal wall 21 and thereby increase the volume
of the working space within the cavity 18. Maintenance of this
insufflation pressure, commonly referred to as pneumoperitoneum, is
particularly difficult where access is desired across the abdominal wall
21, for example, through the trocars 23, 25, as well as the access device
34. For this reason, a substantial effort has been directed to providing
such access devices with sealing characteristics both in the presence of
instruments and in the absence of instruments, such as the grasper 29,
scope 30 and hand 27.

[0061]Thus, the trocars 23 and 25 have typically been provided with
complex valve structures, including, for each narrow range of instrument
sizes, an instrument valve which forms an instrument seal in the presence
of an instrument, and a zero valve which forms a zero seal in the absence
of an instrument. By providing both an instrument seal and a zero seal
the valve structures have been able to inhibit the escape of gases
through the trocars both in the presence and the absence of an
instrument, respectively.

[0062]The instrument seals have been particularly cumbersome, as noted,
and have only been effective for a small range of instrument diameters.
For example, separate instrument seals have been needed for instruments,
such as guidewires, which may have a diameter of only two French to three
French. For medium-sized instruments having diameters of three millimeter
to five millimeters, a second instrument seal has been required. In some
cases, even a third instrument seal has been necessary in order to
accommodate instruments having diameters such as nine millimeters to 12
millimeters.

[0063]Typically the varying sizes of instruments have also required
individual zero seals for each range. Thus, in a complex trocar, such as
the trocar 23, there might be as many as six separate seals associated
with the access device.

[0064]Were it not for the desire to maintain the pneumoperitoneum, there
would be no need for the trocars 23, 25 or the access device 34. One
would merely cut an incision in the abdominal wall 21 and insert the
instrument directly through the incision. However, without appropriate
valves or seals, the insufflation gases would merely escape through the
incisions. This would be particularly detrimental in the case of the
incision 32 which must be sufficiently large to accept the hand 17 of the
surgeon 14. Thus it is a primary purpose of the access device 34 to form
with the incision 32 an access or working channel 34, and to provide a
valve or other sealing structure across the working channel 34 in order
to maintain the pneumoperitoneum.

[0065]An enlarged view of one embodiment of the access device 34 is
illustrated in FIG. 2 which also shows the abdominal wall 21 and the
incision 32. In this simple form, the access device 34 has the general
configuration of a pad 35, meaning that it is generally flat and disposed
in a plane such as the plane 38. Typically parallel to this plane 38 are
a pair of major surfaces of 41 and 43 which provide the pad 35 with a
substantial surface area. An opening or slit 45 can be formed through the
pad 35, generally along an axis 47 perpendicular to the plane 38.

[0066]When operatively disposed, the opening 45 of the pad 35 is in
communication with the incision 32 and, in this case, forms with the
incision 32, the working channel 36. The alignment of the opening 45 and
incision 32 can occur with the pad 35 disposed exteriorly of the
abdominal wall as illustrated in FIG. 2, interiorly of the abdominal wall
is 21 as illustrated in FIG. 3, or within the abdominal wall 21 as
illustrated in FIG. 4. In any of these positions, operative disposition
of the pad 35 relative to the abdominal wall 21 requires that the pad 35
be maintained in its operative position and that it form a seal around
the incision 32. Referring to the plan view of FIG. 5, these two
functions are accomplished with an adhesive 50 disposed around the
incision 32 between the pad 35 and the abdominal wall 21.

[0067]If this adhesive 50 is formed as a continuous ring 52, as
illustrated in FIG. 5, the pad 35 can be disposed with the ring 52
positioned circumferentially around the incision 32 to form a seal
between the pad 35 and the abdominal wall 21. In the illustrated example,
when the pad 35 is operatively positioned, the escape of insufflation
gases is inhibited between the pad 35 and the abdominal wall 21 by the
adhesive ring 52.

[0068]The escape of insufflation gases is inhibited through the opening 45
of the pad 35 by the self-sealing characteristics of the material forming
the pad 35. This material and its highly advantageous properties are
discussed in significant detail below.

[0069]It will be appreciated that the functions of the adhesive ring 52
can be accomplished in many different ways using many different materials
and shapes. For example, many materials other than adhesives can be used
to maintain the pad 35 in position over the incision 32. The formation of
a seal around the incision 32 can also be accomplished with methods other
than adhesion. Furthermore, the shape of the continuous seal formed by
the adhesive 50 need not be in the shape of a circle. Rather, any
continuous pattern sufficiently large to form a perimeter around the
incision 32 could facilitate the desired sealing relationship. Finally,
it will be noted that the mere placement of the pad 35, for example,
interiorly of the abdominal wall 21 as illustrated in FIG. 3, may produce
a perimeter seal merely as a result of the insufflation pressure.

[0070]A further embodiment of the access device 32 is illustrated in FIG.
6 where elements of structure similar to those previously disclosed or
designated with the same reference numeral followed by the lower case
"a." In this embodiment, the functions of position-maintenance and
sealing are accomplished with an alternative configuration for the access
device itself. The pad 35 in this case is disposed within the incision 32
as illustrated in FIG. 4. However, an external flange 54 and an internal
flange 56 are formed integral with the pad 35.

[0071]When operatively disposed, the external flange 54 is positioned
outside of the abdominal wall 21 while the internal flange 56 is disposed
interiorly of the abdominal wall 21a. In this matter, the pad 35 can be
disposed within the incision 32a and held in position by the flanges 54,
56. When the hand 17 of the surgeon 14 is inserted through the access
device 34, the exterior flange 54 prevents the pad 35a from moving
distally. Similarly, when the hand 17 of the surgeon 14 is withdrawn, the
interior flange 56 prevents the pad 35a from moving proximally

[0072]In this embodiment, the opening 45a extends through the pad 35a as
well as the flanges 54 and 56, and completely defines the working channel
34 through the incision 32.

[0073]The primary seal which is required between the access device 34a and
the abdominal wall 21, can be formed with the adhesive ring 52a as
discussed with reference to FIG. 6. Alternatively, this embodiment
including the interior flange 56 may rely merely upon the surface contact
between the flange 56a and the abdominal wall 21. In this case, the
primary seal can be formed between these structural elements and enhanced
by the pneumoperitoneum pressure which forces the interior flange 56
against the abdominal wall as illustrated by a plurality of arrows 58.
This seal is formed primarily in a radial plan generally perpendicular to
the axis 47.

[0074]The function of the primary seal may be further enhanced by
additional sealing which occurs between the pad 35a and the portions of
the abdominal wall 21 forming the incision 32. In this location, the
abdominal wall 21 is radially compressed by the mere presence of the pad
35 within the incision 32. The resulting pressure produces an axial seal
between the pad 35a and the abdominal wall 21.

[0075]If the adhesive ring 52a is desired for this embodiment, it is most
advantageously placed around the incision 32, between the exterior flange
54 and the abdominal wall 21.

[0076]It will be noted that whenever an instrument, such as the arm 16 or
hand 17 of the surgeon 14, is inserted through the pad 35, the material
of the pad conforms to the surface of the instrument and forms the
instrument seal with the instrument. Accordingly, during the entire
period beginning with insertion of the instrument and ending with
withdrawal of the instrument, there is substantially no loss of
insufflation gas through the pad 35a nor any loss of pneumoperitoneum
within the abdominal cavity 18.

[0077]With further reference to FIG. 7, it will be appreciated that the
arm 16 and hand 17 of the surgeon 14 are merely examples of instruments
which can be inserted through the access device 34a. In the absence of
the instrument, or hand 17 in the case of FIG. 7, the opening or slit 45a
merely closes against itself to form a zero seal, thus preventing the
escape of insufflation gases through the access device 34a. When the
instrument, such as the hand 17, is inserted through the opening or slit
45a, an instrument seal is formed between the material of the access
device 34a and the exterior surface of the instrument. This prevents the
escape of insufflation gases through the access device 34a, even when an
instrument is present. Thus, insufflation pressures can be maintained
within the abdominal cavity 18 whether or not the instrument is in place.
Note that these seals, the zero seal and the abdominal seal, can be
formed as a single valve structure having properties for accommodating a
full range of instrument sizes.

[0078]Formation of the pad 35a will typically be accomplished in a simple
molding process described in greater detail below. In such a process, the
opening or slit 45a may be formed as part of the molding process.

[0079]In most cases, the single access opening 45a will be sufficient to
accommodate the operative procedure. However, a further advantage of the
access device 34a will be particularly appreciated by the surgeon 14 who
requires even more access through the pad 35a. Consider for example, the
surgeon 14 having his/her arm 16 inserted through the opening 45a when
he/she decides that a further instrument is required for the operative
procedure. Under these circumstances, a further opening through the pad
35a can be established by merely inserting the desired operative
instrument through the pad 35a. In this manner, the instrument can create
its own access hole beside the primary opening 45a.

[0080]Particularly for those operative instruments having pointed distal
ends, the instrument can merely be forced through the pad 35a forming its
own access hole, such as the opening 45a, as it is moved distally. This
opening, created by the operative instrument itself, would automatically
form an instrument seal as the instrument is inserted, as well as a zero
seal as the instrument is withdrawn.

[0081]For operative instruments not having pointed distal ends, it is
possible to form a new access hole using a secondary instrument, such as
a trocar obturator. After the access hole is formed, the obturator can be
removed, vacating the access hole to receive the operative instrument.
Throughout this process of initially forming an access hole and
ultimately inserting an operative instrument through the hole, both zero
seals and instrument seals are formed to maintain the pneumoperitoneum.

[0082]With the advantages associated with 1) the formation of an
instrument seal and a zero seal with a single valve accommodating a wide
range of diameters, and 2) the formation of an instrument opening using
the instrument itself, it will be appreciated that the concept of this
invention will typically be embodied with a structure that is
particularly dependent upon the material which forms the access device
34. In a preferred embodiment, the pad 35 is formed of a KRATON/oil
mixture including a KRATON Tri-block with a
Styrene-Ethylene/Butylene-Styrene (S-E/B-S) structure in combination with
a mineral oil. Other tri-block polymers can be used for this application
such as Styrene-Isoprene-Styrene, (S-I-S), Styrene-Butadiene-Styrene
(S-B-S), Styrene-Ethylene/Propylene-Styrene (S-E/P-S) manufactured under
the trademark SEPTON by the Kuraray Co. These general formulas can be
further distinguished by the ratio of the styrene to rubber content: for
example, Grade 1650 is a S-E/B-S tri-block with a 29/71 styrene to rubber
ratio.

[0083]In addition to tri-blocks there are also di-block versions of these
materials where styrene is present at only one end of the formula, for
example, Styrene-Ethylene/Butylene (S-E/B) di-block.

[0084]The various base formulas may also be alloyed with one another to
achieve a variety of intermediate properties. For example KRATON G1701X
is a 70% S-E/B 30% S-E/B-S mixture with an overall Styrene to rubber
ratio of 28/72. It can be appreciated that an almost infinite number of
combinations, alloys, and Styrene to rubber ratios can be formulated,
each capable of providing advantages to a particular embodiment of the
invention. These advantages will typically include low durometer, high
elongation, and good tear strength.

[0085]It is contemplated that the material of the pad 35 may also include
silicone, soft urethanes and even harder plastics which might provide the
desired sealing qualities with the addition of a foaming agent. The
silicone materials can be of the types currently used for electronic
encapsulation. The harder plastics may include PVC, Isoprene, KRATON
neat, and other KRATON/oil mixtures. In the KRATON/oil mixture, for
example, oils such as vegetable oils, petroleum oils and silicone oils
might be substituted for the mineral oil. In the broadest sense, all of
these mixtures can be described generally as a gel. The gel will
typically have properties including an ability to "flow" which approaches
that of a fluid. Particularly in the vicinity of any opening or slit 45
extending through the access device 34, propagation of the opening may be
of concern. Stresses resulting from the presence of an instrument will be
concentrated at the ends of such an opening or slit. For this reason, a
good tear resistance is desired for the gel material. Such a tear
resistance is often inherent in the KRATON/oil mixtures and may be
enhanced by encapsulating the gel in other materials. For example, a low
tear resistant gel could be encapsulated in a urethane sheath to improve
the tear resistant qualities of the resulting products. Such a sheath
need not be elastic but could be comprised, for example, of overlapping
sheets of a non-elastic material.

[0086]Any of the gel materials contemplated could be modified to achieve
different properties such as enhanced lubricity, appearance, and wound
protection, or to provide anti-cancer or anti-microbial activity.
Additives can be incorporated directly into the gel, for example in the
case of pharmaceuticals, or applied as a surface treatment to the gel,
for example, to improve lubricity or appearance. Other compounds could be
added to the gel to modify its physical properties or to assist in
subsequent modification of the surface by providing bonding sites or a
surface charge. Antioxidants and antirads can be added to the mixture to
extend the shelf life of the finished product or increase its ability to
withstand radiation sterilization.

[0087]Sealing materials used in medical access devices of the past have
been chosen primarily for their durometer and elongation. It is these
properties which measure the ability of the material to move into small
spaces and crevices as may be required to form an instrument seal across
the working channel of a trocar. For example, in the past, a silicone
mixture was used in medical valves. This mixture had the following
properties: an ultimate elongation less than about 1000 percent and a
durometer not less than about 5 Shore A.

[0088]These properties of the prior art materials are far exceeded by the
properties associated with the present invention which in some respects
provide a full magnitude of advantage. In fact, the difference between
the materials of the prior art and the materials of the present invention
are sufficiently substantial, that it is perhaps misleading to refer to
the present material as merely a gel. According, the material of the
present invention, having properties including an ultimate elongation
greater than about 1000 percent and a durometer less than about 5 Shore
A, will be referred to herein as an "ultragel."

[0089]In a preferred embodiment of the present invention, the ultragel
includes KRATON and mineral oil and provides a sealing material with the
following properties: an ultimate elongation exceeding about 1500
percent, and a durometer of less than about 200 Bloom. The durometer in
this case is considerably lower than that of the prior art materials. In
fact, the durometer of the present material is so soft it cannot even be
measured on the Shore A scale.

[0090]The resulting elongation and durometer of the present material
facilitates its use with as an access valve which is capable of forming
seals with a full range of instrument sizes, but is also capable of
functioning as a zero seal. Whereas access devices of the prior art may
have required as many as six separate seals in order to accommodate a
full range of instrument sizes, access devices can now be made with only
a single valve formed of the ultragel material.

[0091]In a typical manufacturing process, the KRATON G1651 is mixed with
the mineral oil in a ratio by weight of 1 to 9. In order to manufacture
this material, the combination is heated to a temperature of about
200° centigrade. In a preferred method of manufacturing, the mold
is provided with a circumferential ring insert which is molded into the
gel, and slit inserts which can be removed from the gel to form the
opening or slit 45. The resulting gel can be coated with cornstarch to
reduce tack and cooled at room temperature.

[0092]Many of the properties of the KRATON/oil mixture will vary with
adjustments in the weight ratio of the components. In general, the
greater the percentage of mineral oil, the more fluid the mixture; the
greater the percentage of KRATON, the more rigid the material. Weight
ratios of KRATON to oil as low as 1 to 5 have been contemplated for a
more rigid structure. As the KRATON/oil weight ratio approaches 1 to 10,
the mixture becomes more liquid. Ratios as high as 1 to 15 have been
contemplated for this invention.

[0093]The processing temperature can also vary considerably as it is
primarily dependent on the type of KRATON used. Temperatures in a range
of about 150° centigrade to about 250° centigrade have been
contemplated.

[0094]With an appreciation that these ratios and temperatures can develop
considerably different properties, it is now apparent that these
materials can be layered to provide generally different properties within
each layer. For example, an outer layer might be formed of a KRATON/oil
mixture having more rigid properties, thereby providing the pad 35 with
an outer layer that is more rigid. After that layer is at least partially
cured, another layer of the material can be poured inside of the outer
layer. This second layer might be softer providing the pad 35 with the
significant sealing properties. It has been found that successive layers
will tend to fuse slightly at their interface, but will generally
maintain their separate identities. Additional layers could be added to
provide a progression of properties in a particular device.

[0095]Having discussed the properties desirable for the gel material, and
the process of manufacture, one can now address the other embodiments of
the concept which may provide additional advantages for particular
surgical procedures. An embodiment of the access device 34, shown in its
operative position in FIG. 6, is illustrated by itself in the axial cross
section view of FIG. 8.

[0096]This same embodiment can be reinforced with o-rings 61 and 63 as
illustrated in FIG. 9 where elements of structure are designated by the
same reference number followed by the lower case letter "b." Providing
these o-rings 61 and 63 may facilitate several functions associated with
the access device 34b. For example, the rings 61, 63 will typically aid
in maintaining a radial sealing pressure on all sides of the opening 45b.
The rings 61 and 63 will also tend to maintain the flanges 54b and 56b
respectively, in their generally planar configurations. This further
ensures that the flanges 54, 56 will not collapse into the incision 32
with the insertion or withdrawal of an instrument, such as the surgeon's
hand 17. Of course, the o-rings 61 and 63 must be sufficiently large to
accommodate the instrument during insertion and removal.

[0097]A further embodiment of the invention is illustrated in FIG. 10,
where elements of structure are similar to those previously disclosed are
designated with the same reference numerals followed by the lower case
letter "c." This embodiment includes the pad 35c with the opening or slit
45c. The external perimeter o-ring 61c is inserted molded into the
circumference of the pad 35c. The internal o-ring 63c is coupled to the
pad 35c, for example, by way of attachment to the o-ring 61c for example,
by a membrane 65. In this case, the membrane 65 has a generally
cylindrical configuration and elastomeric properties. In preferred
embodiments, the membrane 65 is formed of urethane, neoprene or isoprene.

[0098]When the embodiment of FIG. 10 is being operatively positioned, the
internal o-ring 63b is initially gathered and inserted through the
incision 32 (FIG. 2). The pad 35c and external o-ring 61c are left
outside the incision 32 so that the only material extending across the
incision 32 is the membrane 65. It will be noted that in this case, the
working channel 36c is formed by the slit 45c, the cylindrical membrane
65, and the internal o-ring 63b.

[0099]In this particular embodiment, the pad 35c functions generally as
described with reference to FIG. 2. The primary seal between the pad 35c
and the abdominal wall 21 can be formed either with a circumferential
ring, such as the adhesive ring 52c, or by relying on the sealing
characteristics of the insufflation gas against the internal o-ring 63b
and membrane 65.

[0100]This embodiment of FIG. 10 is of particular advantage as it
incorporates the pad 35c in perhaps its simplest configuration, while
providing a primary seal between the device 34c and the abdominal wall 21
which is facilitated by the insufflation pressure. Furthermore, the
membrane 65 enhances the sealing characteristics of the device 34c, and
provides a lining for the incision 32. With the membrane 65, the incision
32 need not be stretched to a diameter greater than that required by any
instrument inserted through the working channel 36c.

[0101]A further embodiment of the invention is illustrated in FIG. 11
where elements of structure similar to those previously disclosed are
designated with the same reference numeral followed by the lower case
letter "d." This embodiment is similar to that of FIG. 8 in that it
includes the pad 35b, slit 45d, exterior flange 54d, and internal flange
56d. The embodiment of FIG. 11 differs from that of FIG. 8 in that it
includes a lead-in cavity 70 which is in communication with the slit 45d.

[0102]In a preferred embodiment, this cavity 70 is sized and configured to
receive the arm 16 of the surgeon 14 in a manner illustrated in FIG. 7.
In this case, the slit 45d would function primarily to maintain a zero
seal, while the portions of the pad 35d or flange 54d which form the
cavity 70 would function primarily to form the instrument seal.

[0103]A further embodiment of the invention is illustrated in the plan
view of FIG. 12 and the cross section views of FIGS. 13 and 14. In this
embodiment, elements of structure similar to those previously discussed
are designated with the same reference numeral followed by the lower case
letter "e." In this case, the lead-in cavity has the general shape of a
cylinder 72 with an axis that is collinear with the axis 47e of the pad
35e.

[0104]As perhaps best illustrated in FIG. 13, the slit 45e has a
trapezoidal configuration. Thus, it begins proximally with a narrow
length which may generally be equivalent to the diameter of the cylinder
32. From the cavity 70e, the length of the slit 45e increases with
progressive positions distally through the pad 35e. In the illustrated
embodiment, the trapezoidal slit 45e is formed as the frustum of an
isosceles triangle.

[0105]A further embodiment of the invention is illustrated in FIGS. 15 and
16 wherein elements of structure similar to those previously described
are designated with the same reference numeral followed by the lower case
letter "f." As previously discussed with reference to FIG. 12, this
embodiment of the pad 35f is formed with a proximal surface 71 and a
distal surface 73. The pad 35f also includes the coaxial lead-in cylinder
72f and the trapezoidal slit 45f. However, in this case, a duck-bill
valve 74 is provided to further enhance the characteristics of the zero
zeal. As illustrated, the working channel 36f is formed by the lead-in
cavity 70f, the slit 45f, and an extension of the slit 45f which is
defined by the duck-bill valve 74f.

[0106]The duck-bill valve 72 can be formed with opposing flanges 76 and 78
which extend distally of the distal surface 73. When operatively
disposed, the pad 35f can be positioned with its distal surface 73
against the exterior surface of the abdominal wall 21 (FIG. 2) and with
the flanges 76 and 78 extending into the incision 32. With this
configuration and operative disposition, the abdominal wall 21 at the
incision 32 will produce opposing forces on the flanges 76 and 78 which
tend to close the slit 45f, particularly in the absence of an instrument.
In this manner, the duck-bill valve 74 can be relied on to enhance the
characteristics of the zero seal.

[0107]A further embodiment of the invention is illustrated in FIGS. 17 and
18 wherein elements of structure similar to those previously discussed
are designated by the same reference numeral followed by the lower case
letter "g." In this embodiment of the access device 34g, the pad 35g can
be formed generally as discussed with reference to FIG. 13. In this
embodiment, however, the pad 35g can be enclosed along its sides and the
distal surface 73g, by a base 81. In this case, the pad 35g might be
formed by the highly elastic material previously discussed, while the
base 81 might be formed of a more rigid but nevertheless flexible
material such as a urethane. With this configuration, the duck-bill valve
74f would be structured to extend distally of a distal surface 83
associated with the base 81. This would enable the duck-bill valve 74f to
be formed of the base material rather than the superelastic material.
This might also improve the zero seal characteristics for particular
operative applications.

[0108]Another simplified form of the invention is illustrated in FIGS. 19
and 20, where elements of structure similar to those previously discussed
or designated with the same reference numeral followed by the lower case
letter "h." The lead-in cavity 78h, in this case, is formed as an
inverted cone 77 having its base at the proximal surface 71h and its apex
in proximity to the distal surface 73h. Thus, the lead-in cavity 70h has
an area in radial cross section which decreases with progressive
positions distally through the pad 35h. In this embodiment, the proximal
regions near the base of the cone 87 form the instrument seal, while the
distal regions at the apex of the cone form the zero seal. The conical
configuration of the lead-in cavity 70h also tends to funnel an
instrument into the opening 45h leading distally to the apex of the cone
87.

[0109]It will be appreciated generally, that the slit 45 and lead-in
cavity 70 can be provided with many different individual and cooperative
configurations. By way of example, perhaps the simplest form for the pad
35 is illustrated in the embodiment of FIGS. 21 and 22 wherein elements
of structure similar to those previously described are designated by the
same reference numeral followed by the lower case letter "j." In this
embodiment, the pad 35j with its proximal surface 71j and distal surface
73j, is provided with a simple trapezoidal slit 45j. In this case, the
slit 45j extends between the proximal surface 71j and the distal surface
73j.

[0110]The slit 45j in this embodiment of FIG. 21 is typical of many
structures which will define the slit 45j with a planar configuration. In
such a case, the portions of the pad 35j which form the slit will
comprise opposing planar surfaces such as those designated by the
reference numerals 90 and 92 in FIG. 22.

[0111]It will be apparent that the slit 45 need not be formed by opposing
surfaces having a planar configuration. Nevertheless, these opposing
surfaces need to be capable of coming into sealing contact with each
other in order to establish the zero seal. Other slit configurations
capable of accomplishing this function, may offer further advantages in
particular procedures. Other examples of slit configurations are
illustrated merely by way of example in FIGS. 23-26.

[0112]The embodiment of FIG. 23 is similar to that of FIG. 22 in that the
opening 45j comprises a single slit which extends from the proximal
surface 71j to the distal surface 73j. In the case of the FIG. 22
embodiment, the axis 47j is disposed within the plane of the slit 45j. In
the case of the FIG. 23 embodiment, the plane of the slit 45j does not
include the axis 47j. Rather, the slit 45j is formed in a plane which has
an angular relationship with the axis 47j, the proximal surface 71j, as
well as the distal surface 73j. This construction enables the slit 45j to
have a length greater than the thickness of the pad 35j.

[0113]In the embodiment of FIG. 24, elements of structure similar to those
previously discussed are designated with the same reference numeral
followed by the lower case letter "k." In this case, the opening 45k is
configured as two slits 94 and 96 formed in individual planes that are
angularly spaced with respect to each other. Of course, two or more of
the planar slits 94 and 96 may be equally angularly spaced around the
axis 47k. In one embodiment, the individual planar slits 94 and 96
intersect at the axis 47k. Alternatively, the slits 94 and 96 may be
axially spaced in order to facilitate formation of the instrument seal.

[0114]In the embodiment of FIG. 25, elements of structure similar to those
previously discussed are designated with the same reference numeral
followed by the lower case letter "m." In this embodiment, the opening
45m is defined as a slit 98 having a curved rather than planar
configuration. In the illustrated embodiment, the curved slit 98 is
formed as a spiral around the axis 47m. Along the axis 47m, the opposing
surfaces forming the spiral slit 98 can "flow" into sealing proximity in
order to produce the zero seal.

[0115]FIG. 26 illustrates a similar embodiment including a spiral slit. In
this figure, elements of structure similar to those previously discussed
are designated by the same reference numeral followed by the lower case
letter "n." The spiral slit 98n in this embodiment is also formed around
the axis 47n of the pad 35n, but in this case the portions forming the
slit 98n do not extend completely to the axis 47n. As a result, an axial
channel 100 is formed at least partially along the axis 47n. This channel
100 can function in a manner similar to the lead-in cavity 70 discussed
with reference to FIGS. 11-12. This channel 100 can even be formed with a
conical configuration similar to that discussed with reference to FIG.
19.

[0116]In an embodiment where the channel 100 is left open, a zero seal
might be provided by positioning a septum valve across the channel 100.
Such an embodiment is illustrated in FIG. 27, wherein the septum valve is
designated with a reference numeral 101 and the other elements of
structure similar to those previously discussed are designated with the
same reference numerals followed by the lower case letter "p." Thus the
embodiment of FIG. 27 includes the spiral slit 98p, the pad 35p, and the
axis 47p. This embodiment of FIG. 27 is merely representative of many
other embodiments that will combine a slit, such as the slit 98p, with
other valve structures, such as the septum valve 101.

[0117]Other curved slit configurations would include embodiments wherein
the slit is curved, sinusoidal, or S-shaped in a side elevation view.
Such configurations provide a slit part having a length greater than the
thickness of the pad. Normally, the more circuitous the slit path, the
better the sealing characteristics.

[0118]A further and more complex configuration for the opening 45 is
illustrated in the embodiment of FIG. 28 wherein elements of structure
similar to those previously disclosed are designated with the same
reference numeral followed by the lower case letter "q." This embodiment
is representative of many other complex embodiments which can be formed
with intricate shapes and different materials in order to accomplish the
desirable function of forming, with a single valve, a zero seal as well
as an instrument capable of accommodating a full range of instrument
sizes. In the embodiment of FIG. 28, the pad 35q is formed with a base
110 which is disposed circumferentially of a core 112. In this case, the
core 112 is formed of the superelastic material or gel and provided with
the shape of the cone 87q as discussed with reference to FIGS. 19 and 20.
The base 110 is formed from a material that may not be elastic, but
preferably is flexible. In the preferred embodiment, the base 110 is
formed of a urethane.

[0119]In this construction, the base 110 is provided with a plurality of
spokes 114 each of which extends radially inwardly from a base 116 to a
tip 118. The core 112 extends from the axis 47q outwardly to the tips 118
of the spokes 114. In the illustrated embodiment, the core 112 has
fingers 121 which extend beyond the tips 118 and toward the bases 116
between each adjacent pair of the spokes 114. These fingers 121 extend
radially outwardly to an end surface 123 which stops short of the base
116 leaving a void 125 therebetween.

[0120]The voids 125 are of particular interest to this embodiment and can
be incorporated into any of the embodiments previously discussed. Such
voids 125 provide a space or absence of material into which the highly
elastic material, such as that of the fingers 121, can expand during
insertion of an instrument such as the arm 16 (FIG. 7). Since the gel
material is almost fluid in its properties, the voids 125 permit
expansion of the gel with very little resistance. Voids, such as the
voids 125 in the embodiment of FIG. 28, can be defined solely in the gel
material or between the gel material and any other base material.

[0121]In the case of FIG. 28, the spokes 114 and fingers 121 are defined
generally in planes which are parallel to the axis 47q. Similar fingers,
illustrated in the embodiment of FIG. 31 are defined generally in a plane
which is perpendicular to the axis. In this embodiment, elements of
structure similar to those previously disclosed are designated by the
same reference numeral followed by the lower case letter "r." As
illustrated, the pad 35r can be formed with a relatively large opening
45r having the configuration of a coaxial cylinder 130. A plurality of
fingers or flaps 132 extend into the opening 45r and tend to form a
lead-in cavity 70r with properties such as those discussed with reference
to FIG. 19. In this case, the annular flaps 132 have a conical
configuration extending from a base 134 to an apex 136. It will be noted
that the areas between the flaps 132, form voids 125r into which the
flaps 132 can be displaced upon insertion of an instrument, such as the
arm 16.

[0122]A further embodiment of the invention is illustrated in FIG. 32
where elements of structure similar to those previously disclosed are
designated with the same reference numeral followed by the lower case
letter "s." This exploded view of the access device 34s includes not only
the pad 35s but also a complimentary structure for maintaining the
position of the pad 35s, for forming a seal between the pad 35s and the
abdominal wall 21, and for dilating the incision 32 to a variable extent
as required by the surgeon 14. In this case, the access device 34s
includes three components, a gel cap 143, base 145, and a retraction
sheath 147.

[0123]The gel cap 143 includes not only the gel pad 35s, but also a
circumferential cap ring 154 which can be inserted and molded to the pad
35s. The resulting gel cap 143 forms a seal with the base 145, thereby
defining the working channel 36s through the pad 35s, the cap ring 154,
the base 145, and the retraction sheath 147. In the manner previously
discussed, this working channel 36s includes the single valve formed by
the gel pad 35s which provides both a zero seal and an instrument seal
for a wide range of instrument diameters.

[0124]The structure associated with the gel cap 143 is described in
greater detail with reference to FIGS. 33 and 34. In the plan view of
FIG. 33, it can be seen that this embodiment includes the gel pad 35s
centrally disposed within the circumferential cap ring 154. Holding tabs
156 can be provided to extend radially outwardly of the cap ring 154.
These holding tabs 156 can facilitate the sealing engagement of the gel
cap 143 with the base 145 in the manner described in greater detail
below.

[0125]The gel pad 35s can be formed of any of the materials previously
discussed although the preferred embodiment includes the KRATON/mineral
oil gel. The cap ring 154 for such an embodiment can be advantageously
formed of KRATON only. This will make the cap ring 154 more rigid than
the gel pad 35s while maintaining an excellent material interface between
the pad 35s and the ring 154. In a typical manufacturing operation, the
cap ring will be pre-disposed in the mold for the gel pad 35s with the
unitary structure of the gel cap 143 resulting.

[0126]The cross section view of FIG. 34 shows the gel cap 143s and
illustrates an annular void 158 formed on the inner circumference of the
cap ring 154. This void 158 is of particular advantage in forming a
sealing relationship with the base 145 in the manner discussed in greater
detail below.

[0127]The base 145 of this embodiment is shown in greater detail in the
plan and cross section of views of FIGS. 34 and 35, respectively. From
these views it will be noted that the base 145 can be provided with a
smooth generally cylindrical inner surface 161 which extends proximally
to a rounded end surface 163 and outwardly from the end surface 163 along
an annular lip 165. A plurality of tabs 167 can be equally spaced to
extend outwardly and distally around the circumference of the lip 165.

[0128]Distally of the inner surface 163, an annular flange 170 can be
provided with an annular projection 172 sized and configured to form the
desired sealing relationship between the gel cap 143 and the base 145.
The process of molding the base 145 can be facilitated by forming the
base as two separate components divided, for example, by a dotted line
174 in FIG. 35. In a preferred embodiment, the base 145 is molded from a
polycarbonate material.

[0129]A preferred embodiment of the retracting sheath 147 is illustrated
in FIG. 37. In this view it can be seen that the retraction sheath 147
includes a tubular wall 175 which has the configuration of the frustum of
a cone 176 at its distal end and the configuration of a cylinder 177 at
its proximal end. A flexible retaining ring 152 terminates the distal end
while a fold 154 is formed at the proximal end. The tubular wall 175 is
illustrated to include an outer surface 180 and an inner surface 181. In
a preferred embodiment, the sheath 147 is formed of an elastomer, such as
neoprene, so its frustule conical and cylindrical configurations exist
primarily in the natural unstretched state.

[0130]As the sheath 147 is stretched axially, the diameter of the
cylindrical proximal end increases thereby placing radial forces on the
incision 32. The more the sheath 147 is stretched axially, the greater
becomes the diameter of the sheath and consequently the larger becomes
the opening through the incision 32. This feature is of particular
advantage as it permits the surgeon to define the size of the incision 32
with an appropriate degree of axial tension on the sheath 147. By
maintaining this tension, the preferred size of the incision 132 is
maintained throughout the operation. In a preferred apparatus and method,
the axial tension is maintained by stretching the sheath 147 over the
tabs 167 (FIG. 34) of the base 145. Indicia 182 can be printed on the
sheath 147 to provide an indication of the relationship between the axial
stretch of the sheath 147 and the size of the incision 32.

[0131]The fold 153 is provided to facilitate a grip on the proximal end of
the sheath 147. This fold 153 can also function to provide reinforcement
where the walls of the sheath 147 engage the tabs 167 of the base 145. In
the embodiment illustrated in FIG. 38 additional folds 184, 186 are
provided at spaced axial locations, such as those defined by the indicia
182 in FIG. 37. With these folds 184 and 186, additional points of
reinforcement are provided to engage the tabs 167 while providing the
sheath 147 with predetermined degrees of axial stretch associated with
different sizes of the incision 32.

[0132]The method of using the embodiment of FIG. 32 is illustrated the
progressive use of FIGS. 39-42. In FIG. 39, a top plan view of the
abdominal wall 21 of the patient 10 is illustrated with a template 195
positioned to facilitate location of the incision 32. The size of the
incision 32 can be determined with the indicia 182 on the template 195
showing, for example, multiple lengths of a line 197, each length being
equated with a glove size for the surgeon's hand 17 (FIG. 7). Knowing
his/her glove size, the surgeon will merely cut the incision in
accordance with an appropriate length of the line 197. The longer lengths
of the line 197 are associated with the larger incisions, the larger
glove sizes and accordingly the larger hands 17. After the incision 32
has been cut along the line 197, the template 195 can be removed.

[0133]As illustrated in FIG. 40, the retraction sheath 147 can then be
mounted through the incision 32. Initially the ring 152 is compressed and
fed through the incision 32. On the inner surface of the abdominal wall
21, the ring 152 is free to expand to its larger diameter, as shown by a
dotted line 158 in FIG. 40. The portions of the wall 176 which define the
cylinder 177 are left to extend proximally through the opening 32 as
shown in FIG. 40.

[0134]Prior to or after inserting the sheath 147, the base 145 can be
disposed around the incision 32. Then the exposed portions of the sheath
147 will extend through the incision 32 and within the circumferential
base 145. As illustrated in FIG. 41, the wall 176 of the sheath 147 can
then be drawn proximally, outwardly of the page in FIG. 41, to axially
stretch the sheath 147. As noted, when the sheath 147 is axially
stretched, it will create radial forces on the abdominal wall 21 which
will tend to enlarge the incision 32. The greater the axial stretch, the
larger the incision 32.

[0135]When the incision 32 has the desired size, the stretched sheath 147
can be drawn over the tabs 167 to maintain the axial stretch and the
desired size for the incision 32. Either the indicia 182, as shown in
FIG. 36, or the additional folds 184 and 186 as shown in FIG. 37, can be
aligned with the tabs 167 to provide a predetermined size for the
incision 32. At this point, the seal between the abdominal wall 21, the
sheath 147, and the base 145 is fully established.

[0136]A final step remaining in this process is the attachment of the gel
cap 143 to the base 145. This is accomplished as illustrated in FIG. 36
by capturing the lip 172 of the base 145 in the annular void 158 of the
gel cap 143. Bending the holding tabs 156 upwardly and outwardly
facilitates this engagement which ultimately forms a seal between the
base 145 and the gel cap 143.

[0137]Although this invention has been disclosed with reference to certain
structural configurations, it will be appreciated that these products are
merely representative of many different embodiments of the invention.
Accordingly, one is cautioned not to limit the concept only to the
disclosed embodiments, but rather encouraged to determine the scope of
the invention only with reference to the following claims.